Clinical Outcomes of Trimethoprim/Sulfamethoxazole in Critically Ill Patients with Stenotrophomonas maltophilia Bacteremia and Pneumonia Utilizing Renal Replacement Therapies.

Background: The clinical outcomes of usual doses of Trimethoprim-sulfamethoxazole (TMP/SMZ) for treating S. maltophilia in critically ill patients on renal replacement therapies (RRT) have not been established. We sought to assess the clinical outcomes of TMP/SMZ in patients with sepsis utilizing RRT. Methods: A retrospective study was performed on all critically ill adult patients with S. maltophilia infections who received RRT between May 2015 and January 2022. The primary endpoint was clinical cure while the secondary endpoints were microbiologic cure, 30-day infection recurrence, and mortality. Results: Forty-five subjects met the inclusion criteria. The median age was 70.0 [interquartile range (IQR): 63.5-77] years, 57.8% were males, and the median body mass index was 25.7 [IQR: 22-30.2] kg/m2. Clinical success and failure were reported in 18 (40%) and 27 (60%) cases, respectively. There was no significant difference between the 30-day reinfection rates of both groups; however, mortality was significantly higher in the clinical failure group, involving 12 patients (44.4%), versus none in the clinical success group (p = 0.001). The median daily dose of TMP/SMZ upon continuous veno-venous hemofiltration was 1064 [IQR: 776-1380] mg in the clinical cure group vs. 768 [IQR:540-1200] mg in the clinical failure group (p = 0.035). Meanwhile, the median dose for those who received intermittent hemodialysis was 500 [IQR: 320-928] mg in the clinical success group compared to 640 [IQR: 360-1005] mg in the clinical failure group (p = 0.372). A total of 55% experienced thrombocytopenia, 42% hyperkalemia, and 2.2% neutropenia. The multivariable logistic regression analysis showed that the total daily dose at therapy initiation was the only independent factor associated with clinical success after adjusting for different variables including the body mass index [Odds ratio 1.004; 95% confidence interval: (1-1.007), p = 0.044]. Conclusions: Although the S. maltophilia isolates were reported as susceptible, TMP/SMZ with conventional doses to treat bacteremia and pneumonia in critically ill patients utilizing RRT was associated with high rates of clinical and microbiologic failure as well as with mortality. Larger outcomes and pharmacokinetics studies are needed to confirm our findings.

Clinical outcomes of ceftolozane-tazobactam dosing in patients with sepsis undergoing renal replacement therapies.

Ceftolozane-tazobactam (C/T) recommended dosing in patients undergoing renal replacement therapies (RRT) is lacking evidence. The objective of this study was to evaluate the clinical outcomes of C/T dosing in patients on RRT. MATERIALS AND METHODS: A retrospective descriptive study conducted at our institution between May 1, 2017, and March 15, 2022. The primary endpoint was to determine the clinical cure for patients who received C/T for documented infection while on RRT. The secondary endpoints were the microbiologic cure, 30-day infection recurrence, and 30-day crude mortality. RESULTS: Of the 27 patients who met the inclusion criteria, 17 (63%) were males, median age was 69 (62 - 82) years, and weight 67 (57 - 79) kg. The majority of patients had pneumonia 19 (70.4%) followed by bacteremia 5 (18.5%). Multidrug resistant Pseudomonas spp. was the causative organism of infection in 22 subjects (81.5%). Clinical cure was achieved in 17 subjects (63%). Of the 14 subjects who had their culture repeated, 10 (71.4%) patients had microbiologic cure vs. 4 (28.5%) patients who had a microbiologic failure (p = 0.327). 30-day infection recurrence occurred in 6 (35.3%) patients of the clinical cure group and 2 (20%) patients in the clinical failure group (p = 0.362), while mortality occurred in 5 (29.4%) subjects vs. 7 (70%) in both groups, respectively (p = 0.049). The most frequently used doses of C/T were 1.5 g IV q8h while undergoing continuous venovenous hemodiafiltration and 0.75 g IV q8h while undergoing hemodialysis (p = 0.209). The median duration of therapy was 9 (4.5 - 13) days in the clinically cured group vs. 5 (3.75 - 5.5) days in those who had clinical failure (p = 0.038). There was no adverse event reported using these doses during the study period. CONCLUSION: The used doses of C/T in this study were higher than those approved by the U.S. FDA, while clinical success is uncertain. Larger outcomes and pharmacokinetics studies are needed to establish effective dosing and therapy duration.

Sustaining Life versus Altering Life-Saving Drugs: Insights to Explain the Paradoxical Effect of Extracorporeal Membrane Oxygenation on Drugs.

There has been a substantial increase in the use of extracorporeal membrane oxygenation (ECMO) support in critically ill adults. Understanding the complex changes that could affect drugs' pharmacokinetics (PK) and pharmacodynamics (PD) is of suitable need. Therefore, critically ill patients on ECMO represent a challenging clinical situation to manage pharmacotherapy. Thus, clinicians' ability to predict PK and PD alterations within this complex clinical context is fundamental to ensure further optimal and, sometimes, individualized therapeutic plans that balance clinical outcomes with the minimum drug adverse events. Although ECMO remains an irreplaceable extracorporeal technology, and despite the resurgence in its use for respiratory and cardiac failures, especially in the era of the COVID-19 pandemic, scarce data exist on both its effect on the most commonly used drugs and their relative management to achieve the best therapeutic outcomes. The goal of this review is to provide key information about some evidence-based PK alterations of the drugs used in an ECMO setting and their monitoring.

Microbiologic outcomes of ceftazidime-avibactam dosing in patients with sepsis utilizing renal replacement therapies.

INTRODUCTION: The suggested dose of ceftazidime-avibactam (CEF/AVI) in patient with multidrug resistant organisms and utilizing renal replacement therapies (RRTs) is not validated in clinical studies. The objective of this study was to evaluate the microbiologic cure of bacteremia and pneumonia using the recommended CEF/AVI dosing in patients utilizing RRT. METHODS: A retrospective observational study conducted at our institution between September 15, 2018 and March 15, 2022. The primary end point was to determine the microbiologic cure. The secondary end points were the clinical cure, 30-day recurrence, 30-day all cause mortality. RESULTS: Fifty-six patients met the inclusion criteria, 36 (64.3%) were males, the median age was 69 (59.5-79.3) years, and the median weight was 69 (60-83.8) kg. Pneumonia represented 34 (60.7%) of infections. Microbiologic cure was achieved in 32 (57%) subjects. However, clinical cure was achieved in 23 (71.9%) patients in the microbiologic cure group versus 12 (50%) in the microbiologic failure group (p = 0.094). The 30-day recurrence occurred in 2 (6.3%) patients in the microbiologic cure group versus 3 (12.5%) in the microbiologic failure group (p = 0.673). Further, the 30-day all-cause mortality was 18 (56.3%) versus 10 (41.7%) in both groups respectively (p = 0.28). The most used dose in patients utilizing continuous veno-venous hemofiltration (CVVH) was 1.25 g q8h, while the dose was 1.25 g q24h in those who utilized intermittent hemodialysis (IHD). The multivariate logistic regression indicated that bacteremia (OR 41.5 [3.77-46]), Enterobacterales (OR 5.4 [1.04-27.9]), and the drug daily dose (OR 2.33 [1.15-4.72]) were independently associated with microbiologic cure. CONCLUSION: Microbiologic cure of ceftazidime-avibactam in patient utilizing CVVH and IHD is dependent on bacteremia diagnosis, the drug daily dose, and bacterial species. These findings need to be replicated in a larger prospective study, with no recommendations in those utilizing RRT.

Outcomes of a Pharmacy Internship Program at a Quaternary Care Hospital.

OBJECTIVE: To design, implement, and evaluate a Hospital-based Pharmacy Internship Program that meets the educational requirements of  pharmacy graduates to register as competent pharmacists in the United Arab  Emirates. METHOD: The Pharmacy Internship Program was designed as a 6-month, full- time, competency-based program. Intern performance was assessed through  monthly continuous evaluations. Interns who successfully completed the  program were eligible to take the Department of Health Licensing Examination. Pharmacy intern surveys were collected to assess their overall satisfaction with the program. RESULTS: Over the previous 5 years, the program has trained 53 interns. All  interns completed the 6-month training program. Of the 53 graduates, 45  completed the post-internship survey. Interns reported a high level of satisfaction with the program structure and content. CONCLUSIONS: The Pharmacy Internship Program structure was successful in its first 5 years of implementation and was both feasible and sustainable. The  program was viewed as highly beneficial for the professional and personal  growth of pharmacy interns and provided them with the necessary competencies and skills to successfully enter the workforce.

OBJETIVO: Diseñar, implementar y evaluar un programa de prácticas de farmacia dentro de un hospital que cumpliera con los requisitos formativos de los graduados en farmacia y les permitiese posteriormente  acceder al examen de licencia para ejercer como farmacéuticos en los Emiratos Árabes Unidos.Método: El programa de prácticas de farmacia fue diseñado como un programa de 6 meses, a tiempo completo, y enfocado a la adquisición de  competencias. El desempeño de los participantes se evaluó minuciosamente mediante un método de evaluación continua mensual. Los  participantes que completaron con éxito el programa podían presentarse al  Examen del Departamento de Salud (examen de licencia) para obtener  la  licencia de farmacéutico. Se realizaron encuestas a los participantes del programa para evaluar su satisfacción general con el mismo. RESULTADOS: El programa ha capacitado a 53 participantes en los últimos 5  años. Todos los participantes completaron el programa de prácticas de 6  meses. De los 53 graduados que participaron, 45 completaron la encuesta  sobre el programa de prácticas. Los participantes manifestaron una gran  satisfacción con el formato y el contenido del programa. CONCLUSIONES: La estructura del programa de prácticas en farmacia hospitalaria fue un éxito en sus primeros 5 años de existencia y  resultó ser viable y sostenible. El programa se consideró altamente beneficioso para el crecimiento profesional y personal de los participantes y les proporcionó las competencias y habilidades necesarias para incorporarse con  éxito al mundo laboral.

Is Cefoxitin a Carbapenem Sparing Agent in the Management of Urinary Tract Infections Caused by ESBL Producing Enterobacterales?

Background: Cefoxitin has shown in vitro activity against Extended-Spectrum ß-Lactamase (ESBL) producing Enterobacterales. Outcome data regarding cefoxitin as a carbapenem sparing agent in the management of urinary tract infections (UTI) are scarce. We sought to evaluate the clinical and microbiologic efficacy of cefoxitin as compared to ertapenem. Methods: A retrospective observational study was conducted at our quaternary care institution between May 2015 and March 2019. We identified all patients who received cefoxitin for the treatment of UTI during the study period and used Charlson Comorbidity Index to select a matching cohort from patients who received ertapenem. Primary end points were clinical and microbiological cure. Results: Thirty patients who received cefoxitin were matched with 55 patients who received ertapenem. Clinical cure was marginally in favor of ertapenem: 83.2% in cefoxitin group versus 96.8% in ertapenem group (P = .042). However, 90-day recurrence was in favor of cefoxitin: 13.5% in cefoxitin group versus 34.8% in ertapenem group (P = .045). Microbiologic cure was not significant between the 2 groups with 88.6% success in cefoxitin versus 100% in ertapenem. Additionally, the group difference on 30-day recurrence or relapse rates and the 90-day mortality rate were not clinically significant. Conclusion: Cefoxitin achieved similar microbiologic cure rate when compared to ertapenem for the treatment of UTI caused by ESBL-producing Enterobacterales. No significant differences were found in 30-day recurrence/relapse or mortality rates. Larger randomized controlled trials are required to identify the clinical sittings in which cefoxitin could be used as a carbapenem-sparing agent in the treatment of UTI.

Assessment of antibiotic appropriateness at discharge: experience from a quaternary care hospital setting.

Background: There is a gap in antimicrobial stewardship in transitions of care. Objectives: To assess the appropriateness of antibiotics utilized and prescribing habits at hospital discharge. Methods: A retrospective, observational study was conducted at our quaternary care hospital between January 2021 and March 2021. During the study period, all patients discharged on antibiotics for pneumonia (PNA), skin and soft tissue infections (SSTI), urinary tract infections (UTI) and intra-abdominal infections (IAI) were included. The overall appropriateness of therapy was assessed based on the following combined criteria: agent, dose, frequency, duration of therapy, and ability to meet diagnostic criteria. Results: One hundred and forty-five subjects met the inclusion criteria. Of these, 44 (30.3%) were determined to have received overall appropriate antibiotic therapy. The most common infections were UTI, followed by IAI, PNA, and SSTI, respectively. Further, from the group deemed to have received overall inappropriate therapy, 26 of the 101 (25.7%) patients received an inappropriate antibiotic choice, 6 (5.9%) an inappropriate dose, and 84 (83.2%) an inappropriate duration of therapy. Conclusions: Inappropriate duration of therapy represented the most challenging problem with antibiotic regimens at discharge. Larger studies are needed to identify potential interventions that are effective, and can be implemented in all settings, including resource-limited ones.

Resultados de un programa de prácticasde farmacia en un hospital terciario de referencia / Outcomes of a Pharmacy Internship Program at a Quaternary Care Hospital

Objetivo: Diseñar, implementar y evaluar un programa de prácticas defarmacia dentro de un hospital que cumpliera con los requisitos formativosde los graduados en farmacia y les permitiese posteriormente accederal examen de licencia para ejercer como farmacéuticos en los EmiratosÁrabes Unidos.Método: El programa de prácticas de farmacia fue diseñado como unprograma de 6 meses, a tiempo completo, y enfocado a la adquisiciónde competencias. El desempeño de los participantes se evaluó minuciosamente mediante un método de evaluación continua mensual. Los participantes que completaron con éxito el programa podían presentarse alExamen del Departamento de Salud (examen de licencia) para obtener lalicencia de farmacéutico. Se realizaron encuestas a los participantes delprograma para evaluar su satisfacción general con el mismo.Resultados: El programa ha capacitado a 53 participantes en los últimos 5 años. Todos los participantes completaron el programa de prácticas de 6 meses. De los 53 graduados que participaron, 45 completaronla encuesta sobre el programa de prácticas. Los participantes manifestaron una gran satisfacción con el formato y el contenido del programa.Conclusiones: La estructura del programa de prácticas en farmaciahospitalaria fue un éxito en sus primeros 5 años de existencia y resultóser viable y sostenible. El programa se consideró altamente beneficiosopara el crecimiento profesional y personal de los participantes y les proporcionó las competencias y habilidades necesarias para incorporarsecon éxito al mundo laboral. (AU)

Objective: To design, implement, and evaluate a Hospital-based PharmacyInternship Program that meets the educational requirements of pharmacy graduates to register as competent pharmacists in the United Arab Emirates.Method: The Pharmacy Internship Program was designed as a 6-month,full-time, competency-based program. Intern performance was assessedthrough monthly continuous evaluations. Interns who successfully completed the program were eligible to take the Department of Health LicensingExamination. Pharmacy intern surveys were collected to assess their overall satisfaction with the program.Results: Over the previous 5 years, the program has trained 53 interns.All interns completed the 6-month training program. Of the 53 graduates,45 completed the post-internship survey. Interns reported a high level ofsatisfaction with the program structure and content.Conclusions: The Pharmacy Internship Program structure was successfulin its first 5 years of implementation and was both feasible and sustainable. The program was viewed as highly beneficial for the professional andpersonal growth of pharmacy interns and provided them with the necessary competencies and skills to successfully enter the workforce. (AU)

Outcomes of caspofungin use in the treatment of Candida-related urinary tract infections, a case series.

Echinocandins are generally excluded in the treatment of Candida-related urinary tract infections due to their poor urinary concentration. In the presence of fluconazole resistant Candida species, such as C. Glabrata and C. auris, alternative therapies are needed. We herein report the use of caspofungin for the treatment of 10 patients with candiduria, including C. auris. Mycological cure was achieved in 6 of 7 patients and clinical cure was achieved in 8 of 10 patients. Larger studies are needed to confirm our findings.

Tocilizumab and COVID-19: Timing of Administration and Efficacy.

Elevated concentrations of interleukin-6 have been demonstrated to be an important key factor in COVID-19 host immune impairment. It represents an important prognostic factor of harm associated with COVID-19 infection by stimulating a vigorous proinflammatory response, leading to the so-called "cytokine storm". Therefore, immunomodulatory interventions targeting interleukin-6 receptor antagonism have been investigated as potential treatments to counterbalance the host immune dysregulation and to support the advantageous effects of corticosteroids. Tocilizumab is a recombinant humanized monoclonal antibody that has gained much interest during the COVID-19 pandemic as an interleukin-6 receptor antagonist. Various early observational studies have reported beneficial effects of tocilizumab. Moreover, consequent randomized controlled trials have subsequently shown significant positive results about tocilizumab efficacy and safety, focusing on outcomes like mortality, risk of intensive care unit admission, and the need for mechanical ventilation, while others presented conflicting findings. In this review, we first described the pathophysiology of COVID-19 infection while highlighting the role of interleukin-6. Furthermore, we also discussed the non-conclusive evidence about tocilizumab to be used as the standard of care therapy for all patients with COVID-19 pneumonia, as well as its beneficial effects in selected patients.

COVID-19: breaking down a global health crisis.

Coronavirus disease 2019 (COVID-19) is the second pandemic of the twenty-first century, with over one-hundred million infections and over two million deaths to date. It is a novel strain from the Coronaviridae family, named Severe Acute Respiratory Distress Syndrome Coronavirus-2 (SARS-CoV-2); the 7th known member of the coronavirus family to cause disease in humans, notably following the Middle East Respiratory syndrome (MERS), and Severe Acute Respiratory Distress Syndrome (SARS). The most characteristic feature of this single-stranded RNA molecule includes the spike glycoprotein on its surface. Most patients with COVID-19, of which the elderly and immunocompromised are most at risk, complain of flu-like symptoms, including dry cough and headache. The most common complications include pneumonia, acute respiratory distress syndrome, septic shock, and cardiovascular manifestations. Transmission of SARS-CoV-2 is mainly via respiratory droplets, either directly from the air when an infected patient coughs or sneezes, or in the form of fomites on surfaces. Maintaining hand-hygiene, social distancing, and personal protective equipment (i.e., masks) remain the most effective precautions. Patient management includes supportive care and anticoagulative measures, with a focus on maintaining respiratory function. Therapy with dexamethasone, remdesivir, and tocilizumab appear to be most promising to date, with hydroxychloroquine, lopinavir, ritonavir, and interferons falling out of favour. Additionally, accelerated vaccination efforts have taken place internationally, with several promising vaccinations being mass deployed. In response to the COVID-19 pandemic, countries and stakeholders have taken varying precautions to combat and contain the spread of the virus and dampen its collateral economic damage. This review paper aims to synthesize the impact of the virus on a global, micro to macro scale.

Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease.

BACKGROUND: Pulmonary radiological findings of the novel coronavirus disease 2019 (COVID-19) have been well documented and range from scattered ground-glass infiltrates in milder cases to confluent ground-glass change, dense consolidation, and crazy paving in the critically ill. However, lung cavitation has not been commonly described in these patients. The objective of this study was to assess the incidence of pulmonary cavitation in patients with COVID-19 and describe its characteristics and evolution. METHODS: We conducted a retrospective review of all patients admitted to our institution with COVID-19 and reviewed electronic medical records and imaging to identify patients who developed pulmonary cavitation. RESULTS: Twelve out of 689 (1.7%) patients admitted to our institution with COVID-19 developed pulmonary cavitation, comprising 3.3% (n = 12/359) of patients who developed COVID-19 pneumonia, and 11% (n = 12/110) of those admitted to the intensive care unit. We describe the imaging characteristics of the cavitation and present the clinical, pharmacological, laboratory, and microbiological parameters for these patients. In this cohort six patients have died, and six discharged home. CONCLUSION: Cavitary lung disease in patients with severe COVID-19 disease is not uncommon, and is associated with a high level of morbidity and mortality.

Comprehensive Approach to Reduce Surgical Site Infections in Patients Undergoing Neurosurgical Procedures.

Background: Surgical site infections (SSIs) are recognized complications of surgical procedures. Methicillin-resistant Staphylococcus aureus (MRSA) colonization increases the likelihood of developing SSIs. Decolonization of MRSA has been shown to reduce post-operative SSIs, therefore, the aim of this project was to identify and decolonize MRSA carriers and to tailor perioperative antibiotic prophylaxis to protect those at high risk for SSIs better. Methods: In September 2013, a quality improvement process initiative was implemented for pre-operative screening of MRSA nasal carriage for patients undergoing elective neurosurgical procedures. Those identified as colonized received a 10-day decolonization protocol that consisted of: oral doxycycline 100 mg twice daily or oral trimethoprim-sulfamethoxazole (TMP-SMX) DS twice daily; oral rifampin 600 mg daily; daily bathing with chlorhexidine; and twice daily use of mupirocin ointment in each nostril and under the fingernails. In addition to cefazolin (weight-based dosing), vancomycin (weight-based dosing) was recommended for perioperative prophylaxis in known MRSA carriers and patients undergoing surgical procedures involving hardware implantation irrespective of colonization status. We compared the results with our previously documented neurosurgical site infection rates (2012 and 2013 were 3.0 and 2.2%, respectively) Results: From 2014 to 2015, MRSA screening was done for 1,197 patients, of whom 52 (4.3%) were found to be colonized. Surgical site infections occurred in 14 procedures (1.4%) in 2014 and eight (0.8%) procedures in 2015, respectively. Methicillin-resistant Staphylococcus aureus remained responsible for most of these infections. None of the patients who underwent decolonization developed an infection (MRSA or otherwise). Conclusions: The overall rate of neurosurgical site infections can be reduced through a bundled approach of MRSA decolonization and change in perioperative antibiotic prophylaxis to include vancomycin for procedures involving hardware implantation irrespective of MRSA carriage state.

Treatment of severe pneumonia due to COVID-19 with peginterferon alfa 2a.

The outbreak of the new coronavirus disease 2019 (COVID-19) has spread rapidly worldwide. Until now, no definite effective treatment has been identified. We reported 3 patients with severe COVID-19 treated with pegylated interferon alfa 2a with satisfactory recovery. Based on these observations, randomized studies with interferons should be considered in deteriorating patients infected with COVID-19.

Cefiderocol: A Siderophore Cephalosporin.

OBJECTIVE: This article reviews the available data on the chemistry, spectrum of activity, pharmacokinetic and pharmacodynamic properties, clinical efficacy, and potential place in therapy of cefiderocol. DATA SOURCES: A literature search through PubMed, Google Scholar, and ClinicalTrials.gov was conducted (2009 to March 2020) using the search terms cefiderocol and S-649266. Abstracts presented at recent conferences, prescribing information, and information from the US Food and Drug Administration (FDA) and the manufacturer's website were reviewed. STUDY SELECTION AND DATA EXTRACTION: All relevant published articles, package inserts, and unpublished meeting abstracts on cefiderocol were reviewed. DATA SYNTHESIS: Cefiderocol is the first siderophore antibiotic to be approved by the FDA. It was shown to be active against a wide range of resistant Gram-negative pathogens, including multidrug-resistant (MDR) Pseudomonas aeruginosa, Acinetobacter baumannii, Enterobacteriaceae, and Stenotrophomonas maltophilia. Cefiderocol was studied in the treatment of adult patients with complicated urinary tract infections (cUTIs) and nosocomial pneumonia and was well tolerated. In a recently completed prospective study, higher mortality was observed with cefiderocol in the treatment of serious infections caused by carbapenem-resistant (CR) Gram-negative pathogens. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The approval of cefiderocol provides a new option in the treatment of cUTIs and potentially treatment of nosocomial pneumonia caused by resistant Gram-negative pathogens. Given the higher mortality observed with cefiderocol, its use in the treatment of CR Gram-negative infections should be carefully considered. CONCLUSION: Cefiderocol shows promising activity against MDR Gram-negative pathogens. Its use in the treatment of serious infections caused by CR Gram-negative bacteria needs further evaluation in phase III clinical studies.

The Impact of Integrating Rapid PCR-Based Blood Culture Identification Panel to an Established Antimicrobial Stewardship Program in the United Arab of Emirates.

BACKGROUND: Studies have shown improvement in the outcome of blood stream infections (BSI) due to the use of Rapid PCR-Based Blood Culture Identification Panel (BCID) in Antimicrobial stewardship programs (ASP). There is currently no data on the use of BCID with ASP in the United Arab Emirates (UAE). METHOD: Pre-post quasiexperimental study included hospitalized patients with BSI, their positive blood cultures on BCID were studied in 2 groups: conventional culture with ASP (AS), and BCID with ASP (BCID). The primary outcomes were time to first appropriate antimicrobial therapy, infection related length of stay (LOS), ICU admission, 14 days bacteremia recurrence and in-hospital mortality. Secondary outcomes were 30 days reinfection rate, hospital cost and ASP interventions. RESULTS: Out of total 477 positive blood cultures, 206 (AS and BCID) with real BSI were included. The time needed for organism identification was shorter in the BCID group than in the AS group (1.3 h vs. 51 h; P = 0.0002). BCID had a shorter time to appropriate antimicrobial therapy than AS (17.8 h vs.45 h; P = 0.0004). No statistical difference was observed in mortality rate, 14 days bacteremia recurrence, ICU admission, hospital cost, LOS or ASP interventions. CONCLUSION: Implementing BCID to ASP significantly decreased the time needed to identify the organism and time to appropriate antimicrobial therapy. Similarly, LOS and hospital cost were reduced, however, the reduction was not statistically significant.

A case of acute disseminated encephalomyelitis following Mycoplasma pneumoniae infection.

We report a case of acute disseminated encephalomyelitis (ADEM) secondary to Mycoplasma pneumoniae infection that failed to improve with methylprednisolone and intravenous immunoglobulin (IVIG); who responded with plasmapheresis. A 21- year- old female with an unremarkable medical history, initially presented to an outside hospital with fever and an influenza-like illness and was subsequently intubated for worsening sensorium. Brain magnetic resonance imaging was suggestive of ADEM or vasculitis for which she received five days of pulse steroids and IVIG. She showed no signs of improvement and was transferred to our hospital for plasmapheresis. Her work up revealed an elevated IgM antibody and positive sputum for Mycoplasma pneumonia by polymerase chain reaction, suggesting the pathogen as the culprit for her ADEM. Intravenous azithromycin and daily plasmapheresis were initiated for seven consecutive days. Following commencement of her treatment, the patient experienced good recovery and was subsequently extubated. She continued to improve with physical therapy and gained mobility, with the help of a walker. Patients commonly present with ADEM following viral infection or vaccination and less frequently post bacterial infection. The current treatment of ADEM due to Mycoplasma pneumoniae is based on limited case reports. Our patient poorly responded to pulse steroids and IVIG, while she markedly improved on azithromycin and plasmapheresis. In patients presenting with encephalopathic signs and neurological manifestations following pneumonia; Mycoplasma pneumoniae infection and subsequent immune-mediated demyelination should be considered.

Comparison of antimicrobial activity between ceftolozane-tazobactam and ceftazidime-avibactam against multidrug-resistant isolates of Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa.

OBJECTIVE: This study compared the activity of ceftolozane-tazobactam and ceftazidime-avibactam against 120 bacterial strains, including extended-spectrum beta-lactamase (ESBL) producers, carbapenem-resistant Enterobacteriaceae (CRE), and Pseudomonas aeruginosa, isolated from patients admitted to Cleveland Clinic Abu Dhabi, United Arab Emirates. METHODS: In vitro susceptibility was tested using the Etest strip minimum inhibitory concentration (MIC) method, and PCR was used to characterize the carbapenemase enzymes produced by CRE strains. RESULTS: All 29 ESBL isolates were susceptible to ceftazidime-avibactam (MIC50 0.125µg/ml), whereas all but one were susceptible to ceftolozane-tazobactam (MIC50 0.38µg/ml). Twenty-seven (45%) CRE isolates were susceptible to ceftazidime-avibactam (MIC50 ≥256µg/ml), whereas only six (10%) isolates were susceptible to ceftolozane-tazobactam (MIC50 ≥256µg/ml). Very few NDM-1 isolates were susceptible to ceftazidime-avibactam, whereas the majority of OXA-48 isolates were susceptible. Twenty-nine (94%) P. aeruginosa isolates were susceptible to ceftazidime-avibactam (MIC50 1.5µg/ml), whereas 30 (97%) isolates were susceptible to ceftolozane-tazobactam (MIC50 0.75µg/ml). CONCLUSIONS: Ceftolozane-tazobactam and ceftazidime-avibactam showed comparable activity against ESBL and P. aeruginosa, with ceftazidime-avibactam having lower MICs against ESBL isolates and ceftolozane-tazobactam having lower MICs against P. aeruginosa. Ceftazidime-avibactam showed better activity against all CRE isolates except for those carrying the NDM-1 enzyme.